ROTATOR CUFF TENDINITIS AND TEAR

Rotator cuff is the group of tendons in the shoulder joint providing support and enabling a wider range of motion. Injury to these tendons may result in a tear of these tendons. It is one of the most common causes of shoulder pain in middle aged adults and older individuals.

Causes

Rotator cuff tears result from impingement of the rotator cuff on part of the shoulder blade (acromion) as the arm is lifted. It may occur with repeated use of the arm for overhead activities, while playing sports or during motor accidents. Tears of the rotator cuff can also occur from a fall, shoulder dislocation or heavy lifting. Rarely deposits of calcium or uric acid on the rotator cuff tendons called Calcific tendinitis can also predispose to tears.

Symptoms

Rotator cuff tears often cause severe pain, weakness of the arm, and crackling sensation on moving the shoulder in certain positions. There may be stiffness, swelling, loss of movements, and tenderness in the front of the shoulder.

Diagnosis

A Rotator Cuff Tear diagnosis is based on the physical examination, X-rays, and imaging studies, such as Ultrasound, MRI, Ct Arthrogram or MR Arthrogram. Rotator cuff tears are best viewed on magnetic resonance imaging (MRI). A tear involving less than 50% of thickness or one that is in a non-dominant extremity and not causing disability may be treated conservatively. A tear greater than 50% of the thickness and in a dominant extremity causing disability with work or activities of daily living may need surgery. In old tears which are separated and the muscle has degenerated, repair may not be always possible. If early arthritis has set in due to old tears, a CT scan may be required to assess the degree of arthritis.

Conservative Treatment Options

  • Rest
  • Shoulder sling
  • Non-steroidal anti-inflammatory medication if Dr Bala agrees you are not at a high risk of complication, injection of a steroid (cortisone) and a local anaesthetic in the subacromial space of the affected shoulder to help decrease the inflammation and pain

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  • Certain exercises to help strengthen the tendons after healing.
  • Ultrasound shock wave therapy for calcific tendinitis
  • In rare instances Dr Bala may opt to use cells from your own blood that are rich in undifferentiated cells. This preparation is called Platelet Rich Plasma or PRP. This injection may aid healing of minor tears of the rotator cuff.

 

Surgery

Rotator cuff repair may be performed by either an open surgery or arthroscopic procedure.

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The first step in rotator cuff repair, is to remove the bursa between the arm bone and the shoulder blade (subacromial bursectomy). Then the space for rotator cuff tendons will be increased by shaving some bone off the under surface of the shoulder blade (subacromial decompression). Concomitant shoulder pathology such as arthritis of the joint between the collar bone and the shoulder blade (AC joint arthritis), or the long head of the biceps tendon (bicipital tendinitis) are usually addressed simultaneously. For AC joint arthritis the joint surfaces of the AC joint are excised either through key hole surgery or open surgery. If there is degeneration of the portion of the long head of biceps tendon (long head bicipital tendinitis) Dr Bala prefers to cut the tendon within the joint and fix it at the upper end of the arm bone with a small metal button. This procedure is called biceps tenodesis and maybe done either through key-hole or open surgery.

If the cause is calcific tendinitis the calcium deposits are removed using a needle (barbotage) and a small keyhole instrument called the shaver.

The rotator cuff tear is initially cleaned of unhealthy tissue. The point of attachment of the tendons (footprint) is prepared to promote tendon to bone healing. The tendons are then mobilized and the defect in the tendons is approximated and then repaired using suture anchors. These suture-anchors help in attaching the tendons to the arm (humerus) bone. Dr Bala may use either a single or double rows of suture anchors depending on the tear pattern and your shoulder needs. He prefers a mini open repair, as in his hands, the repair is much more robust and he can start moving your shoulder straight away without restrictions. He also uses a technique called the suture bridge technique for his repairs.

 

Some tendons are retracted so much that a nerve release (Suprascapular nerve release) may be necessary to prevent stretching of the nerve after rotator cuff repair. Some defects in the tendons are too large to be approximated. In such instances, Dr Bala may opt to perform a procedure called Superior Capsular Reconstruction using a synthetic graft to fill the defect.

On rare occasions if the defect is not mobilizable and early shoulder arthritis has set in, Dr Bala may decide in your best interests that a reverse shoulder replacement will be a better option for you.

The subscapularis is one of the rotator cuff tendons in the front of the shoulder. A tear may be fixed either through keyhole or open surgery.

Following surgery, recovery is slow, a sling is required and you may be advised to practice motion and strengthening exercises.

Dr Bala specializes in salvage of complications of surgery, failed surgery or of neglected rotator cuff tears.